Name: _______________________________________ Specialty: _________________________
Name in Thai: ________________________________________
Street Address: ______________________________________________________________________________
City/State/ZIP: _______________________________________________________________________________
Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Fax: ( _ _ _ ) _ _ _ - _ _ _ _
E-mail address: ___________________________________
Type of work for Mission:
A. Surgery [ ] C. Education [ ]
B. Outpatient Care [ ]
Days available for Mission:
A. January 31 to Feb.4, 2011 Yes [ ] No [ ]
B. Other [Please specify dates – between January 31 – Feb.4, 2011
__________________________________________________________
Accompanied by:
A. Spouse: Name: _________________________________ Work: _______________________
B. Children (preferred undergraduate level or higher) must be assigned to their parents or
their designated adults.
Name: ____________________________________________________
School / University: _________________________________________
Purpose: Education: __________________________ Work: ________________________
Documents required for Thai temporary license to practice medicine and nursing:
(Non Thai Graduated)
1. Two color photos [size 1”] 5. A letter stating where, when and the duration
2. Curriculum Vitae of the Medical Mission you plan to attend.
3. A copy of your Diploma 6. A copy of your picture document page of
4. A copy of your current license your passport
Please return application to:
Dr. Soontorn Thrupkaew, M. D. Address: P.O.BOX 208, Bethalto ,IL 62010
Tel: (618) 4630317,Mobile (618)3348403 Fax: (618) 4331259 email: soontornt@yahoo.com